Part 2.
TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
Chapter 126.
GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS
28 TAC §§126.5 - 126.7
The Commissioner of the Division of Workers' Compensation,
Texas Department of Insurance, adopts amendments to §126.5 and §126.6
and new §126.7, concerning required medical evaluations, entitlement
and procedures for requesting a designated doctor. The new and amended sections
are adopted with changes to the proposed text as published in the February
3, 2006, issue of the
Texas Register
(31 TexReg
664).
The new and amended sections are necessary to implement changes to the
Labor Code §§408.004, 408.0041, and 408.151 as a result of House
Bill (HB) 7, enacted by the 79th Legislature, Regular Session. HB 7 amended
Labor Code §408.004 to limit the use of a required medical examination
(RME) prior to a designated doctor examination to only the resolution of issues
regarding the appropriateness of the health care received by an injured employee
(employee). HB 7 also amended Labor Code §408.0041 by expanding the scope
of issues a designated doctor may be requested to address. The amendments
to §126.5 and §126.6 and new §126.7 are necessary to implement
amendments to Labor Code §§408.004, 408.0041 and 408.151 which establish
the requirements and processes for requesting and scheduling an RME and designated
doctor examination. These adopted rules reflect the Division's efforts to
implement the statutory requirements of HB 7 with stakeholder input and public
comment. The Division has made changes to the sections based on public comment
and for clarification purposes. The Division added notification to the employee's
representative, if any, where appropriate in §126.6 and §126.7 as
suggested by commenters. The other changes are more fully discussed below
in this preamble.
Section 126.5 provides procedural direction and guidance regarding the
reasons and timeframes an RME may be requested and granted. Consistent with
Labor Code §§408.004, 408.0041 and 408.151, §126.5 specifies
the reasons and times during the lifetime of the claim an insurance carrier
or the Commissioner of Workers' Compensation may require an RME. The Division
has made changes to §126.5 as a result of public comment to clarify that
it's the requesting party's responsibility to ensure that an RME doctor does
not have a disqualifying association and to change the number of days from
10 to 15 for an employee to agree to an examination. Other changes have been
made for clarification purposes.
Section 126.6 provides procedural direction and guidance regarding scheduling
RMEs, rescheduling RME appointments when there is a scheduling conflict, filing
of reports by the RME doctor, suspending of temporary income benefits (TIBs)
when the employee fails to attend, without good cause, a required medical
examination following a designated doctor examination, and the reinstating
of TIBs when the employee submits to a rescheduled examination.
Subsection (a) provides that the Division will grant or deny the requests
for an RME within seven days of receipt of the request. The Division will
provide a copy of the notice for the RME to the injured employee, employee's
representative, if any, and the insurance carrier. Subsection (a) also requires
the notice to provide information that failure to attend the examination may
result in the loss of benefits and an administrative penalty. Subsection (b)
requires a rescheduled examination resulting from a schedule conflict be rescheduled
within seven days of the originally scheduled exam unless the employee and
RME doctor agree to an extension. Based on public comment, the Division has
added language to limit the amount of time for an extension to 30 days from
the originally scheduled exam. Subsection (e) requires a report to be filed
regarding the findings of the RME by the RME doctor who performed an examination
regarding the appropriateness of medical care received by the injured employee
pursuant to §408.004. It also provides with whom the report shall be
filed and the manner in which the report is to be filed. Based on comments
received, the Division has added a description of when a notice is considered
verifiable. The Division has also made changes to subsections (f), (h), and
(j) as a result of public comments. The changes include notice to the employee
and employee's representative, if any, of the MMI or impairment rating; require
an RME to file a narrative report within seven days of the exam if it addresses
issues other than those in subsections (f) and (g); require an RME doctor
to reschedule an exam as soon as possible but no later than 30 days after
contact from the employee if TIBs have been suspended; reinstate TIBs as of
the date the employee submits to the exam; and reinitiate TIBs when the carrier
is notified that the employee had good cause for not attending the exam.
New §126.7 provides procedural direction and guidance regarding the
request for, and selection of, a designated doctor consistent with the amendments
to Labor Code §408.0041. The section also provides procedural direction
and guidance regarding the scheduling of the designated doctor examination,
the suspension of TIBs for failure to attend the examination without good
cause, the reinstatement of TIBs when the injured employee submits to the
examination, and the responsibilities of the designated doctor. As a result
of public comment, the Division made changes to subsection (e)(5) to clarify
that the Division will appoint a new designated doctor if an exam cannot be
rescheduled with the existing designated doctor within 21 days. In subsection
(g) in response to comments, the Division has changed the requirement for
reinstatement of TIBs to submission to the exam rather than rescheduling the
exam. The Division also added that TIBs is reinstated when the carrier is
notified that the employee had good cause for not attending the exam. The
Division has changed subsection (i) to clarify that when using the same designated
doctor only those records not previously submitted have to be provided for
a subsequent exam and deleted the requirement that original records be left
intact. The Division made changes to subsection (j) to clarify that a medical
history should be obtained from the employee. In subsection (k), the testing
completion requirement of seven days has been changed to 10 days as well as
changing the trigger for filing the report from utilizing another health care
provider to the need for additional testing. Subsections (n), (o) and (p)
specify the required reports for the designated doctor to file pertaining
to the type of examination conducted. The Division has changed subsection
(u) based on public comments to clarify that the designated doctor must be
currently on the list at the time a request is received and that the designated
doctor shall respond within five days to a letter of clarification. The Division
has also changed the requirements when a reexamination is necessary.
General: A commenter states the rules need to be rewritten to eliminate
the worthless and meaningless definitions of the various types of physicians
and the restrictions on the examinations. A commenter believes that the independent
review process becomes meaningless by changing the definitions and authority
of the different physicians in the system. A commenter contends that networks
will make sure these rules don't apply to them so that they may have as many
RMEs and designated doctors as they want.
Agency Response: The Division disagrees that the rules need to be rewritten.
The Division believes the rules provide clarification to doctors who perform
RMEs and information regarding when they may appropriately perform an examination
on an injured employee based on new statutory requirements and restrictions
enacted under HB 7. Labor Code §408.004(f) is clear regarding the applicability
of RMEs for injured employees receiving care through a network. An injured
employee who receives care through a network may not be required to attend
an RME regarding appropriateness of medical care. However, in accordance with §408.0041,
an injured employee receiving care through a network may be required to attend
an RME that addresses MMI/IR, return-to-work, extent of injury or causation
after a designated doctor examination on the same issue.
§126.5: A commenter states that there should only be "treating doctor"
and "independent medical examination physicians." He contends the designated
doctor process has been destroyed over the years.
Agency Response: The Division disagrees that there should only be two types
of doctors in the system, and no designated doctors. Labor Code §404.0041
requires designated doctors to be in the system.
Comment: A commenter questions who determines what is "unbiased," and states
that Hearing Officers and Appeal Panel Decisions cannot be used.
Agency Response: The Division determines what is an unbiased report. The
Contested Case Hearing Officers and Appeals Panel judges make determinations
as to the appropriateness, accuracy and applicability of the differing medical
opinions during the dispute resolution process.
Comment: A commenter states the rule allows for too many "opinions," and
that special training and medical literature should be used to clarify controversies.
Agency Response: The Division disagrees. The statute provides for opinions
by treating doctors, required medical exam doctors, and designated doctors.
Additionally, medical literature may be a resource to doctors in the system,
but it does not take the place of a physical examination of the employee regarding
the specific issues in question or dispute.
Comment: A commenter states that it is horrible that an RME doctor could
become a treating doctor or take over the injured employee's care and that
this should only happen when there is a predetermined special medical need.
Agency Response: The Division disagrees. The employee may choose the RME
doctor as the employee's treating doctor. However, the workers' compensation
healthcare networks may prohibit this type of practice since injured employees
receiving treatment through a network can only be treated by a doctor authorized/approved
by the network.
Comment: A commenter states that networks and employees should be allowed
to request RMEs.
Agency Response: The Division disagrees. Labor Code §408.004 does
not allow a network or an injured employee to request an RME. Only the Commissioner
of Workers' Compensation or the insurance carrier may request or require an
RME.
Comment: A commenter states there should not be a limit on the number of
physicians per claim that can perform an RME, and that any number of RME physicians
per claim could be agreed on and used.
Agency response: The Division disagrees. Labor Code §408.004(b) requires
the use of the same doctor for subsequent exams unless otherwise approved
by the Commissioner.
Comment: A commenter states RME doctors should be required to have the
same level of Division approved training as designated doctors, and that their
decisions should be tracked.
Agency Response: The Division agrees in part and disagrees in part. The
Division agrees that an RME doctor that performs MMI/IR certifications must
be trained and certified by the Division in the same manner as a designated
doctor. They are currently required to meet the same training requirements
for this type of exam as the designated doctor, and this requirement will
continue. The Division disagrees that an RME doctor is required to have the
same level of training across the board as a designated doctor. Not every
RME doctor will be requested to perform the types of exams that designated
doctors will perform. Labor Code §408.1225 requires the designated doctor
to meet specified requirements. There are no equivalent requirements regarding
RME doctors.
Comment: A commenter states it is too much to see another doctor, and that
she loses time getting well waiting on what her primary doctor wants to do.
Agency Response: The Labor Code specifically permits an insurance carrier
to require an exam with a doctor of its choice. If the commenter is unhappy
with the treatment received from the treating doctor, the commenter should
discuss treatment concerns with the treating doctor and consider requesting
a change of treating doctor.
Comment: A commenter requests the Division to specifically state the effective
date of the rule as the effective date for a carrier is on or after the date
provided by the rule.
Agency Response: The effective date of the rules is January 1, 2007. The
Division has specified the date that a request for an RME may be made in §§126.5
- 126.7 and §130.6 as on or after January 1, 2007.
§126.5 and §126.7: A commenter states that the rules lay out
a cumbersome process that many doctors may not want to participate in. The
commenter also believes the rules are positive because they place responsibilities
on the injured employee.
Agency Response: The Division disagrees in part and agrees in part. The
Division disagrees that the rules lay out a cumbersome process and feels that
the rules as written lay out reasonable procedural guidance regarding the
request for and performance of an RME and designated doctor exam. The Division
agrees that the rules place requirements on the injured employee.
§126.5(a): A commenter states there is no Labor Code provision that
prohibits a doctor from performing as an RME doctor because he belongs to
the same network as the employee's treating doctor.
Agency Response: Although there is no provision in the Labor Code for this
prohibition, the Insurance Code §1305.101(b) prohibits a doctor from
performing as a designated doctor or required medical exam doctor on an employee
that is receiving care through a network with which the doctor is employed
or contracted.
Comment: A commenter suggests clarifying up front that prior to a designated
doctor exam an RME may only be used to evaluate the appropriateness of health
care.
Agency Response: The Division has structured the rule in subsection (c)(1),
(2) and (3) to provide clarification as to when an RME may be requested and
scheduled.
§126.5(b): A commenter states the carrier is entitled to an RME under
specified circumstances. The commenter also states that "similar issues" should
not be deleted, and that the proposed language does not track the statute.
Another commenter asserts that Labor Code §408.004(a) and (b) are parallel
provisions. The commenter states that the Division's ability to require an
RME under subsection (a) is "on its own motion," and limited to only the issue
of appropriateness of medical care; however, under subsection (b), the insurance
carrier may request an RME for any reason set forth in §408.004, including
an exam on the issue of "whether treatment should be extended to another body
part or system" and "a change in the employee's condition and whether it is
necessary to change the employee's diagnosis."
Agency Response: The Division disagrees that the insurance carrier is entitled
to an RME under specified circumstances. The Division's interpretation is
that the Division's ability to order an RME, on its own motion or at the request
of the carrier, is restricted to only the issue of appropriateness of medical
care. There is no statutory provision in subsection (a) that an RME may be
ordered only at the Division's own motion. The Division also interprets subsection
(b) to restrict the Division's ability to require an employee to attend an
RME until after the insurance carrier has first attempted to seek the employee's
agreement to attend. The statutory provision the commenter references regarding
exams on issues other than appropriateness of medical care is permissive based
on the Commissioner of Workers' Compensation adopting rules to allow the additional
exams. The Division has determined that the use of additional RME exams as
previously allowed by §408.004 is not a tool that has been widely used.
Division records indicate that in FY2004, only 151 requests for additional
exams were received with 91 being approved. In FY2005, 150 requests were received
with 81 being approved. Additionally, the "similar issues" provision of Labor
Code §408.0041 would seem logical for the types of exams to which the
commenter referred. Labor Code §408.004(b) provides that the Commissioner
of Workers' Compensation may adopt rules that allow up to three medical examinations
in a 180-day period for specific circumstances. The Division is not adopting
rules to allow the additional exams. The Division has determined that this
provision is not necessary, as the designated doctor process will handle the
need for the additional exams.
The Division disagrees that "similar issues" should not be deleted. The
provision for an RME on "similar issues" was removed from Labor Code §408.004
by HB 7 and replaced in §408.0041 regarding designated doctor exams.
§126.5(c)(1) and §126.7(t): Several commenters question why the
additional reasons for requesting an RME more frequently than 180 days are
being deleted. The commenters contend that an RME should be allowed as often
as necessary, not once every 180 days or once a year. Several commenters recommend
amending the section to allow for one RME for return to work every 180 days,
rather than once per year, after the second anniversary of SIBs.
Agency Response: The reason for the deletion of the additional RMEs is
due to previous non-use of the rule to request additional RMEs. The reasons
for the additional RMEs provided in Labor Code §408.004 can be handled
appropriately under the "similar issues" provision of Labor Code §408.0041.
Additionally, by handling the reasons for additional RMEs as a "similar issue"
under §408.0041, the carrier could request the designated doctor exam
on these issues every 60 days rather than every 180 days as allowed by §408.004.
Labor Code §408.004(b) restricts the carrier's ability to obtain an RME
to once every 180 days. The Division disagrees that the insurance carrier
should be able to request an RME for return to work every 180 days. Labor
Code §408.151(a) limits the insurance carrier's ability to require the
injured employee to attend an RME more than once per year after the second
anniversary of entitlement to SIBs.
§126.5(c)(3): Several commenters recommend amending subsection (c)(3)
to allow for one RME for return to work every 180 days, rather than once per
year, after the second anniversary of SIBs. The commenter also states the
insurance carrier should be able to request an RME if the injured employee's
condition worsens after MMI has been certified and the injured employee applies
for lifetime income benefits (LIBs).
Agency Response: The Division disagrees that the insurance carrier should
be able to request an RME for return to work every 180 days. Labor Code §408.151(a)
limits the insurance carrier's ability to require the injured employee to
attend an RME more than once per year after the second anniversary of entitlement
to SIBs.
The Division agrees in part and disagrees in part regarding the comment
that the insurance carrier should be able to request an RME if the injured
employee's condition worsens after MMI has been certified and the injured
employee applies for LIBs. In the situation provided it appears this would
be an extent of injury issue. The Division disagrees that the carrier can
proceed directly to an RME. The Division agrees the insurance carrier should
be able to have a doctor review the extent of the injured employee's injury
in an effort to determine if the injured employee's injury meets the requirement
for LIBs. An examination by the designated doctor under Labor Code §408.0041
is available for this purpose. After the designated doctor's examination,
the insurance carrier will be entitled to an RME on the issue. Additionally,
since entitlement to LIBs is based on the severity of the injury, not on the
injured employee's ability to work, a request for an exam regarding return
to work is not appropriate.
§126.5(d): Several commenters recommend removing the requirement that
an RME doctor to be on the Division's approved doctor list (ADL). Some commenters
also state that many good doctors became unavailable after the ADL went into
effect in 2003 and removing the restriction would make more doctors available,
particularly specialists, such as urologists and psychiatrists.
Agency Response: The Division disagrees. Labor Code §408.023 requires
RME doctors to be on the ADL and thus, these doctors should have the same
training as other doctors practicing within the system. Additionally, an RME
doctor has to be on the ADL to be able to certify MMI/IR. However, pursuant
to Labor Code §408.023(k) the requirements of the ADL expire on September
1, 2007 and this requirement will no longer be in effect.
Comment: A commenter recommends adding language to clarify that the MMI/IR
exam is after a designated doctor exam.
Agency Response: The Division agrees and has changed the language.
§126.5(e): A commenter recommends amending the reference to "subsection
(b)(2) and (3)" to "subsection (c)(2) and (3)" since there is no (b)(2) and
(3).
Agency Response: The Division agrees and has corrected the cite. Additionally,
the Division changed the reference to "subsection (g)" to the appropriate
cite.
§126.5(e)(2): Several commenters recommend deleting "on the fifth
day after," as the time allowed under the current rule is sufficient.
Agency Response: The intent of the proposal was to provide the injured
employee 10 days to reach agreement with the insurance carrier. The outcome
of this intent is that the injured employee has 15 days after the request
is sent, considering §102.5, to reach agreement with the insurance carrier.
The Division has clarified that the injured employee has 15 days to agree
to the insurance carrier's request.
Comment: A commenter states that the injured employee rarely agrees to
attend the RME. The commenter further states there is no legitimate reason
to extend the timeframe for the injured employee to agree to the exam from
10 days to 15 days since the Division almost always approves the carrier's
request. A commenter states that some parties will wait until the 10th day
only to not agree to the exam, prolonging the time required to get approval
for the RME.
Agency Response: The Division disagrees. The employee should be allowed
a sufficient amount of time to make a decision. Additionally, the rule provides
that the adjuster may contact the employee, or the employee's representative,
by telephone to obtain the employee's response.
§126.5(f)(2): A commenter agrees with the deletion of this subsection
from the existing rule. He states the provision created confusion regarding
whether a carrier is allowed a different doctor when the request is pursuant
to Labor Code §408.004 or §408.0041.
Agency Response: The Division acknowledges the comment and agrees that
the carrier may request a different doctor to perform the exam pursuant to
Labor Code §408.004 or §408.0041. The Division does not agree that
the carrier may request different doctors for post-designated doctor exams
based on the multiple issues addressed by the designated doctor. The RME doctor
selected by the carrier for the post-designated doctor exam should be qualified
to address all the issues addressed by the designated doctor.
§126.6: A commenter states it is a waste of time going to the insurance
carrier's doctor. She believes that is why employees don't get well and states
that the insurance carriers think the injured employees are faking.
Agency Response: The Division disagrees. Labor Code §§408.004,
408.0041 and 408.151 entitle an insurance carrier to an exam performed by
a doctor of its choice. Section 408.004 requires an employee to submit to
medical examinations to resolve any question about the appropriateness for
health care received by the employee. Section 408.0041(a) authorizes the Commissioner
to order a medical examination to resolve any questions about (1) the impairment
caused by the compensable injury; (2) the attainment of maximum medical improvement;
(3) the extent of the employee's compensable injury; (4) whether the injured
employee's disability is the direct result of the work-related injury; (5)
the ability of the employee to return to work; or (6) other issues similar
to those described in subdivisions (1) - (5). Section 408.151(b) states that
if a dispute exists as to whether the employee's medical condition has improved
sufficiency to allow the employee to return to work, the Commissioner shall
direct the employee to be examined by a designated doctor chosen by the Division.
Comment: A commenter contends that RMEs are occurring prior to the designated
doctor exam rather than after as required by statute. The commenter recommends
that a statistical analysis of RME doctors' exams be compared with an analysis
of designated doctor exams.
Agency Response: The Division has structured the rule to be consistent
with the statute, which does not authorize or allow this. If the commenter
is aware of violations of the statute and rule occurring, then he should report
these violations to the Division so that appropriate action can be taken.
Comment: A commenter states that since this rule pertains to carrier-selected
and Division-appointed RMEs, it should be noted that the authority to order
exams under Labor Code §408.004 does not apply to health care provided
pursuant to a workers' compensation health care network (WCHCN).
Agency Response: The Division disagrees. Section 126.6 addresses RMEs for
issues other than appropriateness of medical care. It also addresses RMEs
allowed by Labor Code §408.0041, which may be requested by the employee
in addition to the insurance carrier. Section 126.5(c)(1) provides the requested
clarification that RMEs to address appropriateness of medical care may not
be performed on employees receiving medical care through a workers' compensation
health care network.
Comment: A commenter states that since the Division has not repealed §134.650,
regarding Prospective Review of Medical Exams (PRME), it should be stated
in the rule that the Division may not require an RME for employees covered
by a WCHCN.
Agency Response: The Division disagrees. The Division intends to adopt
treatment guidelines in the near future. The adoption of the treatment guidelines,
along with the expanded role of the designated doctor, is anticipated to eliminate
the need for the PRME rule. The Division intends to repeal §134.650 when
the treatment guidelines have been implemented. An exception to the PRME rule
in this rule would be inappropriate at this time. Additionally, the restriction
on the use of a PRME for an injured employee receiving care through a network
can be addressed through procedural guidance and training of Division staff.
Comment: A commenter states that the rules lay out a cumbersome process
that many doctors may not want to participate in. The commenter also believes
the rules are positive because they place responsibilities on the injured
employee.
Agency Response: The Division disagrees in part and agrees in part. The
Division disagrees that the rules lay out a cumbersome process and feels that
the rules as written lay out reasonable procedural guidance regarding the
request for and performance of an RME and designated doctor exam. The Division
agrees that the rules place requirements on the injured employee.
§126.6(a): A commenter questions whether "notice" carries the same
compliance weight as "order," and whether there is a difference between the
two words.
Agency Response: The Division assures the commenter that notice does carry
the same compliance requirement as order. If an injured employee does not
comply with the requirements of the notice, the carrier can still take the
same action that it previously could take for non-compliance. The Division
has merely clarified what its practice has been by changing the word. The
Division was providing notice to the employee but was referring to that notice
as an order. No change has occurred in any of the requirements of the parties
or the need to comply with any of the provisions of the rules. The change
was made to be consistent with the actual practices of the Division and with
those of the Department.
§126.6(a), (b) and (k): Several commenters state that the Division
notice requiring the injured employee to attend an RME should also include
notice that a party may not ignore the order because of some perceived fault
by the Division in approving the request. A commenter states that some attorneys
are advising their injured employee clients not to attend the RME because
the attorney believes the Division should not have approved the request.
Agency Response: The Division disagrees. The Division does not believe
that clarification needs to be provided to advise participants in the workers'
compensation system that failure of one party to comply with statute or rules
does not negate the other party's obligation to comply with statutory or rule
requirements. Failure of a system participant to comply with a requirement
of the Division or the Commissioner of Workers' Compensation may result in
the issuance of an administrative penalty.
§126.6(b): A commenter states the requirement for the exam to be conducted
within 30 days from receipt of the notice, with 10 days notice to the employee,
is unreasonable. Even when scheduling the exam in advance, delays by the Division
make it impossible to meet the required timeframes. The commenter also states
some attorneys are advising their injured employee clients to not attend the
exam if the employee does not receive 10 days notice of the scheduled examination.
A commenter states there is no statutory authority for limiting the amount
of time the order is valid.
Agency Response: The Division disagrees. According to agency records, a
request for an RME is processed, on average, in less than three days from
receipt by the Division. Taking into consideration distribution to the insurance
carrier through the Austin Rep Box, the request for an RME is processed and
a response provided to the carrier within seven days of receipt by the Division.
Failure of one party to comply with statutory or rule provisions does not
negate the other party's obligation to comply with statutes or rules. Failure
of a system participant to comply with a requirement of the Division or the
Commissioner of Workers' Compensation may result in the issuance of an administrative
penalty. The Division is not limiting the amount of time the notice is valid.
The notice of required attendance does not become invalid due to noncompliance
by one of the parties. If the carrier does not meet the requirement to schedule
the exam timely, the carrier may be assessed an administrative penalty. The
injured employee is still required to attend the exam. If the employee does
not attend the exam, the employee is subject to an administrative penalty
and/or suspension of temporary income benefits.
Comment: A commenter states there needs to be a limit on how far out and
how many times an appointment may be rescheduled.
Agency Response: The Division agrees in part and disagrees in part. The
Division disagrees that there needs to be a specific number of times an appointment
can be rescheduled based on scheduling conflicts between the doctor and the
employee as long as communication between the doctor and employee is taking
place. The Division agrees that a limit should be set on how far out the exam
may be rescheduled. Based on the requirement that the exam be initially scheduled
within 30 days, the Division requires the exam to be rescheduled within 30
days of the originally scheduled exam.
§126.6(e) and (g): Several commenters state the rule does not define
"verifiable means" and believe the phrase will be read in context and construed
according to rules of grammar and common usage. A commenter provided definition
language for consideration.
Agency Response: The Division agrees and has added a description of "verifiable
means" to subsection (e) and it is to be used as direction to ensure that
delivery is verifiable. The goal of this requirement is not to regulate how
a system participant makes delivery of a report or other information to another
system participant, but to ensure that the system participant filing the report
or providing the information has verifiable proof that it was delivered.
Comment: A commenter states the doctor should be required to describe how
he believes the injury occurred and that the credibility and persuasiveness
of the doctor is dependent upon what he understands the history of the injury
to be.
Agency Response: The Division disagrees, as making this a requirement would
be very subjective and would call for speculation on the part of the doctor.
The medical information provided to the doctor should contain an objective
history and description of the injury.
§126.6(f) and §126.7(u) and (v): Several commenters state that
"the employee's representative, if any" needs to be added to the report distribution
list, notice of designated doctor appointment distribution list and rescheduled
appointment distribution list.
Agency response: The Division agrees. The language has been added to the
rule. It should be noted that §102.4(b) provides for notification to
the injured employee's representative if the health care provider has been
notified of the representation. If the provider has not been notified of the
representation, the provider has no obligation to provide notice to the representative.
Comment: Several commenters state the rule as written appears to allow
an RME doctor to certify MMI/IR merely after a designated doctor exam, even
if the designated doctor determines the injured employee is not at MMI. They
state the true purpose is to allow an RME doctor to certify MMI/IR only after
the designated doctor has certified MMI/IR.
Agency Response: The Division disagrees that an RME doctor should only
be allowed to certify MMI/IR after the designated doctor has certified MMI/IR.
Labor Code §408.0041(f) allows the insurance carrier to request an RME
if it is not satisfied with the opinion of the designated doctor, not just
when the designated doctor certified MMI/IR. Additionally, refusing to allow
the insurance carrier to seek the opinion of an RME would prevent the carrier
from being able to gather medical evidence to dispute the determination of
the designated doctor.
§126.6(h)(1)(B): A commenter is concerned about the elimination of
subparagraph (B) and believes that injured employees will not attend rescheduled
exams because the deterrent has been removed.
Agency Response: The injured employee is still required to attend a rescheduled
exam and TIBS can still be suspended if an injured employee does not attend
the exam without having good cause. This situation is addressed in §126.6(j)(3).
§126.6(j): A commenter recommends missing an RME required under Labor
Code §408.004(a) should result in suspension of TIBs to the injured employee.
Agency Response: The Division disagrees. Labor Code §408.004(a) addresses
RME exams for appropriateness of medical care. Labor Code §408.004(e)
provides that an employee's failure to attend an RME required under §408.004(a)
constitutes an administrative violation not suspension of TIBs.
§126.6(j)(1)(B): Several commenters recommend deleting the proposed
language and replacing it with the previous language. They state that the
entitlement to TIBs should occur when the employee submits to the exam, not
when he contacts the doctor's office. A commenter states it is unclear how
the carrier will be notified of the date the injured employee contacted the
doctor's office to reschedule the examination and suggested language.
Agency Response: The Division disagrees that the original language should
be replaced as suggested. However, the requirement for reinstatement of TIBs
effective the date the injured employee contacts the doctor's office has been
removed and clarifying language added regarding the rescheduling of the missed
appointment and the reinstatement of TIBs once the injured employee has submitted
to the exam.
§126.6(j)(2): A commenter states there is no statutory provision for
the suspension of TIBs for a missed appointment. The statute provides for
an administrative penalty.
Agency Response: The Division disagrees that there is no statutory provision
for the suspension of TIBs. This section addresses an RME after a designated
doctor exam. Labor Code §408.0041(j) allows for the suspension of TIBs
for failure to attend a designated doctor exam or an RME after the designated
doctor exam. The administrative penalty is in addition to the suspension of
TIBs.
§126.7: A commenter questions if everything in §130.6 has been
moved to this rule, and suggests it should all be in one place. A commenter
recommends that §130.6(d), (e), and (f) be moved to §126.7 to avoid
confusion.
Agency Response: The Division clarifies that not all the requirements of §130.6
have been moved to this rule. The Division disagrees that all designated doctor
language should be in one place. Chapter 126 addresses general provisions
applicable to all benefits. Section 126.7 provides general direction regarding
the request for a designated doctor during any benefit period. Chapter 130,
Subchapter A, specifically addresses issues regarding the certification of
MMI/IR and impairment income benefits. Section 130.6 provides direction specific
to an exam performed for the purpose of certifying MMI by a designated doctor
Comment: A commenter objects to online exams for designated doctors and
wants the practice eliminated. The commenter believes that doctors pay other
individuals to take the exam for them when it is online.
Agency Response: The Division understands the commenter's concern about
people taking exams for other people. There are protocols in place to ensure
that the appropriate person is taking the exam.
Comment: A commenter objects to required medical exams performed by carrier
paid physicians as biased and believes that designated doctors should only
perform RMEs.
Agency Response: The statute permits a carrier to select an RME doctor.
An injured employee's provider may attend an RME with the employee. It is
necessary for a carrier to be able to request an RME to ensure that appropriate
care is being provided to the injured employee. This ability ensures that
there are checks and balances in the system.
Comment: A commenter states that there should be a provision for reimbursement
from the Subsequent Injury Fund (SIF) when the insurance carrier makes an
overpayment of income benefits based on a designated doctor's report.
Agency Response: The Division understands the commenter's concern about
reimbursement of an overpayment. Labor Code §403.006 provides for the
reimbursement from the SIF when there has been an overpayment of benefits
made under an interlocutory order or decision of the Commissioner. The Division
will review the applicable provisions of the Labor Code and rules and make
a determination if this is a matter that can possibly be addressed at a future
date.
§126.7(c)(4) and (5): A commenter feels the designated doctor should
be evaluating the employee's ability to return to any type of work at any
employer, not just the employer at the time of the injury, and suggests changing
the language in paragraphs (4) and (5) to reflect this concept. The commenter
also recommends deleting "similar issues" and further defining other reasons
for examinations by the designated doctor such as "the effects of any intervening
injury or illness on the ability to work or on the impairment rating."
Agency Response: The Division agrees in part and disagrees in part. The
Division disagrees regarding "similar issues" because this is from Labor Code §408.0041(a).
The reasons for requesting a designated doctor exam provided in the rule are
statutory provisions. Only reasons for the exam provided by statute will be
included here.
The Division agrees that the designated doctor should be evaluating the
injured employee's ability to return to any type of work. Neither the statute
nor this rule is intended to limit the exam to the ability to return to work
at the same employer, or the same type of work being performed, at the time
of the injury.
§126.7(d): A commenter requests the Division to define the legal term
"presumptive weight."
Agency Response: The Division declines to define the term "presumptive
weight" because it is a well recognized, commonly understood legal term. Additionally,
the term should be read in conjunction with the remainder of the sentence
in which it is contained, as well as other uses of the term in Labor Code §§408.0041,
408.1225, 408.125, and 408.151. The Division will determine whether the report
of the designated doctor is to be given "presumptive weight" by comparing
it to other evidence. If other evidence exists that counters the report, the
Division may decide not to resolve questions about the employee's injury based
upon the report of the designated doctor.
§126.7(e) and (i)(3): A commenter states that a 14 - 21 day timeframe
to schedule an appointment is unwieldy. He recommends "no earlier than 21
days and no later than 28 days" from the date the exam is set.
Agency Response: The Division disagrees. Labor Code §408.0041(b) requires
the Division to assign a designated doctor not later than the 10th day after
the date under which the request under §408.0041(a) is approved and the
exam to be scheduled no later than the 21st day after the Commissioner issues
the order. The Division expects the medical records to be delivered prior
to the exam to ensure they are there in time for the examination.
Comment: A commenter states the subsection requires the assigning of the
designated doctor but does not articulate standards as to the doctor's qualifications.
The commenter states the statute requires the credentials to be established
by rule and they are not present.
Agency Response: The Division has addressed the qualifications to be selected
as a designated doctor in §180.21, and it is not necessary for the qualifications
to be restated.
Comment: A commenter requests that the rule be amended to prohibit Division
staff from rejecting a request for a designated doctor because the request
is incomplete or contains incorrect information that the commenter feels is
available through the Division's records. The commenter provides recommended
language.
Agency Response: The Division disagrees. The reason the Division requires
the information on the request for a designated doctor is because the insurance
carrier or the injured employee has not always provided the required information
to the Division. There have been many occasions where the request for the
designated doctor exam was the first notice the Division had of the injury
and claims had to be created from the information contained on the request.
Additionally, the carrier and the employee are parties that should have immediate
access to and knowledge of the information required.
§126.7(f): A commenter recommends requiring the rescheduled exam to
occur in seven days, rather than the proposed 14 days.
Agency Response: The Division disagrees. However, the Division has changed
the language to be consistent with the requirement under Labor Code §408.0041
to schedule the initial examination within 21 days. A new designated doctor
may need to be selected by requiring the exam to be rescheduled within seven
days. This change will allow some leeway in facilitating use of the same designated
doctor.
§126.7(g)(2): Several commenters recommend that the precondition to
reinstated TIBs be submitting to the exam, not contacting the doctor's office
to reschedule. Another commenter states that reinstating TIBs when the employee
calls to reschedule the exam will encourage missed appointments. The commenter
also states that the statute allows for suspension of TIBs until the employee
submits to the exam. As such, the rule conflicts with the statute.
Agency Response: The Division agrees. The requirement for reinstatement
of TIBs effective the date the injured employee contacts the doctor's office
to reschedule has been removed. Language has been added regarding the rescheduling
of the missed appointment and the reinstatement of TIBs based on the injured
employee's submitting to the exam.
§126.7(h): A commenter recommends adding a requirement for staff to
document why an alternate designated doctor was selected in DRIS logs or similar
diary system.
Agency Response: The Division disagrees that it is necessary to change
the rule. Generally, Division staff already record this information. This
requirement will be addressed by internal Division procedure.
Comment: A commenter recommends deleting the language "if the doctor is
still qualified and available" from the rule. He recommends that the same
doctor be required to be used, and that common sense can dictate if a new
doctor is needed.
Agency response: The Division disagrees. The language provides that the
same designated doctor shall be used unless there is a reason to select a
different doctor. The language allows the Division to take appropriate action
based on the qualifications or availability of the designated doctor.
Comment: A commenter questions what the timeframe is for a rescheduled
examination. The commenter states a new designated doctor should not be appointed
just because the designated doctor is not readily available, and believes
there should be reasonable leeway for repeat examinations.
Agency Response: The Division notes that an exam rescheduled due to a scheduling
conflict is addressed in §126.7(f), which requires the examination to
be rescheduled within 21 days of the originally scheduled examination. For
a subsequent examination pursuant to subsection (h), the required timeframe
is between the 14th and 21st days after the Division's receipt, as required
by §126.7(e). This change will allow some leeway in facilitating use
of the same designated doctor.
§126.7(h)(1): A commenter states that the 12-month treatment restriction
is insufficient and should be extended to five years. Agency Response: The
Division disagrees. The 12-month restriction was established to prevent a
doctor from examining an employee with whom the doctor has had a recent relationship.
Additionally, imposing a longer restriction may have an adverse impact on
the pool of eligible doctors.
§126.7(h)(3): A commenter suggests defining "credentials appropriate"
and provides recommended language. Agency Response: The Division has addressed
the qualifications to be selected as a designated doctor in §180.21 which
includes meeting certain training requirements as well as being on the approved
doctor's list (ADL). It is not necessary to define the term as the meaning
is understood when the rule is read as a whole.
§126.7(i): Several commenters request that sanctions be imposed against
insurance carriers that provide the designated doctor with an analysis of
the employee's medical condition that is false, misleading, or contains a
misrepresentation.
Agency Response: The Division agrees. There are processes in place to deal
with these types of activities and commenters are urged to report evidence
of wrongdoing to the Division for review and possible follow-up action.
Comment: Several commenters state the employee or the employee's representative
should be able to send a response to the designated doctor if the insurance
carrier sends an analysis.
Agency Response: The Division disagrees. There is no statutory provision
allowing this type of communication. The injured employee's treating doctor
has the ability to provide records and an analysis to the designated doctor.
§126.7(i)(1): A commenter states that the treating doctor and insurance
carrier should only be required to submit medical records to the designated
doctor for the initial examination. He recommends that for repeat examinations,
only the medical records not previously provided should be sent.
Agency Response: The Division agrees and has changed the language.
§126.7(i)(2): Several commenters recommend allowing the carrier and
treating doctor to submit one set of medical records that may contain an analysis
of the injured employee's medical condition, functional abilities, return-to-work
opportunities, video-taped activities as this would help reduce the amount
of paper used and save the designated doctor valuable storage space.
Agency Response: The Division agrees and has changed the language.
Comment: Some commenters state that requiring the medical records to be
received by the designated doctor no later than the fifth working day is unreasonably
short. A commenter provides a scenario where the appointment is scheduled
to occur on the 14th day. Given five days mail time and delivery five days
prior to the exam, there are only four days to process the medical information
and mail it. The commenter recommends amending the language to require the
medical records be mailed no later that the fifth working day prior to the
exam. Another commenter provides a scenario in which the carrier may not be
able to get the medical records to the designated doctor in time. A commenter
states there are other means of verifying delivery, and that repeal of §102.5(d)
will still require a method of verifying the designated doctor's receipt of
a letter of clarification. The commenter also asserts that doctors are out
of their offices and that adequate time should be allowed for them to respond.
Agency Response: The Division agrees with the commenters' recommendation
to extend the time and the language has been changed to "mailed" to allow
extra time. The Division disagrees that §102.5(d) should be repealed.
Section 102.5(d) provides a date certain for determining the date of receipt
when there is no verification of delivery required.
§126.7(i)(4)(A): Several commenters recommend changing "shall" to
"may" since the designated doctor should be able to use his discretion when
reporting that a carrier has not timely provided the medical records prior
to the exam.
Agency Response: The Division disagrees. Without this notice the Division
will not have a ready mechanism to identify potential violations and take
appropriate actions.
§126.7(j): A commenter suggests that the type of information provided
to the designated doctor for review by the injured employee should be specified,
and provides recommended language.
Agency Response: The Division agrees and has made the change.
Comment: A commenter recommends replacing "feels appropriate" with language
that is more objective such as "determines to be appropriate."
Agency Response: The Division agrees and has made the change.
§126.7(k): A commenter states that ordering additional tests should
extend the designated doctor's time to file the report by seven days regardless
of whether another doctor is used or the designated doctor performs the test.
A few commenters recommend changing seven days to 14 days to allow sufficient
time to locate a doctor and schedule the testing.
Agency response: The Division agrees and has changed the length of time
to obtain the additional testing from seven to 10 days. The time to file the
report when additional testing is required was also changed to 10 days. The
time to locate a doctor and get the testing performed has been extended to
10 working days.
§126.7(k): A commenter states that it makes no sense to limit subsequent
examinations to the same designated doctor for subsequent issues if those
issues are different than those previously determined by a designated doctor.
The commenter states that he should not be tied to the notion that one doctor
should be assigned for all issues.
Agency Response: The Division disagrees that there should be multiple designated
doctors based on subsequent issues being raised. Subsection (k) of this rule
allows a designated doctor to refer the employee to other health care providers
when necessary to determine the issue in question.
§126.7(n)(1): A commenter recommends substituting "used" in place
of "reviewed" as some records are so large it would take multiple pages to
list them all.
Agency Response: The Division disagrees. Use of "reviewed" is helpful in
dispute resolution when issues arise regarding the medical evidence/information
used to make the determination. This type of information may also be critical
in reducing the number of letters for clarification regarding whether specific
medical records were considered when making the determination.
§126.7(s): A commenter states this section is unnecessary and that
all designated doctor exam requests are based on good cause. He feels the
Division should not impose a 60-day hurdle for a carrier to get a subsequent
designated doctor exam.
Agency Response: The Division disagrees. The 60-day prohibition, unless
good cause for more frequent exams exist, is statutorily required by Labor
Code §408.0041(b).
Comment: A commenter questions the statutory authority to limit the carrier's
ability to request a designated doctor exam after the second anniversary of
entitlement to SIBs. The commenter states the carrier is prohibited from requesting
an RME under Labor Code §408.151 but not from requesting a designated
doctor.
Agency Response: As the commenter stated, Labor Code §408.151 prohibits
the carrier from requesting an RME after the second anniversary of entitlement
to SIBs. Since a carrier is entitled by Labor Code §408.0041 to an RME
if the carrier is not satisfied with the opinion of the designated doctor,
allowing the carrier to request a designated doctor on the issue of the employee's
ability to return to work more often that once per year would allow the carrier
the opportunity and ability to request or require an RME on return to work
more often that once annually. By restricting the carrier's access to the
designated doctor on the issue of the ability of the employee to return to
work after the second anniversary of entitlement to SIBs, the Division is
restricting the carrier's ability to request/require an RME on return to work
pursuant to §408.151.
§126.7(u): Several commenters recommend striking "This procedure may
only be used to schedule one additional examination" as there is no statutory
basis. Another commenter recommends deleting the last sentence as it is unclear
whether the "one additional examination" is for the life of the claim or for
the particular examination.
Agency Response: The Division has deleted subsections (u) and (v) which
require the designated doctor to reschedule the exam when the doctor determines
the employee is not able to return to work, or has not reached MMI, respectively
as unnecessary.
Comment: A commenter requests clarification that the designated doctor
should evaluate the employee regarding any type of return to work with any
employer, not just the employer at the time of the injury.
Agency Response: The Division disagrees the clarification needs to made.
Since neither the statute or the Division specified that the ability to return
to work was with the pre-injury employer, the designated doctor should be
determining the injured employee's ability to return to work in any capacity.
§126.7(w): A commenter recommends requiring the Division to notify
the requesting party, within 10 days, if the Division elects to not request
clarification and the specific reason for not doing so.
Agency Response: The Division disagrees that it needs to add this requirement
to the rule. The Division currently has a process in place to perform this
function and will continue to utilize this process.
Comment: A commenter questions the authority of the Division to request
clarification from the designated doctor on issues the Division deems appropriate
and believes there is no authority for letters of clarification.
Agency Response: The Division disagrees. Pursuant to Labor Code §402.021(b)(5)
and Chapter 410, the Division has statutory authority to perform dispute resolution
activities to resolve disputes. Requesting letters of clarification is one
way for the Division to try and expedite dispute resolution.
Comment: A commenter states the Division does not have the authority to
compel a designated doctor to be available to conduct another examination
within 10 days of when the designated doctor receives the request.
Agency Response: The Division agrees in part and disagrees in part. Labor
Code §408.0041(a) provides that the Commissioner may order, on his own
motion, a designated doctor exam. Section 408.0041(b) provides that the exam
shall be conducted with 21 days of the Commissioner's order. The language
has been changed to require the rescheduled exam to be conducted within 21
days of the request by the Division.
Comment: A commenter states the rule is ambiguous and confusing. The commenter
contends the requirement to respond to the letter of clarification within
five days of receipt of the request, or within 10 days if the doctor requires
a repeat examination, is impossible. Another commenter states that while there
is a required response time when the doctor needs to reexamine the injured
employee, there is no required timeframe for response when there is no need
for a reexamination.
Agency Response: The Division agrees and has clarified the language.
Comment: A commenter states that not only should the opposing party be
provided a copy of the request for clarification, but also it should have
the opportunity to respond to the request, and suggested language.
Agency Response: The Division disagrees. Allowing the opposing party time
to respond to the request for a letter of clarification will only prolong
the dispute resolution process. Each party has the ability to request a letter
of clarification. Also, each party has the ability to question/dispute the
response provided from the designated doctor's response to the letter of clarification.
Comment: A commenter states that the Division's Appeals Panel has held
that presumptive weight is given to an amended report regardless of whether
the doctor amended the report for a proper reason, and that the "proper reason"
criterion must continue. The commenter recommends that amended reports for
improper reasons should be deemed invalid and not be considered.
Agency Response: The Division disagrees. If a party feels the report has
been amended for an improper reason, the party should request dispute resolution.
Evidence of wrongdoing (amending for improper reasons) should be submitted
to the Division for review and appropriate action.
Comment: A commenter states that the Appeals Panel is split regarding whether
a designated doctor who is no longer on the list is authorized to respond
to a letter of clarification. The commenter recommends that a designated doctor
need not be on the list to respond to the letter of clarification, but must
be on the list to perform an examination.
Agency Response: The Division disagrees. There are several reasons why
a designated doctor may no longer be on the designated doctor list (DDL).
The reasons include, but are not limited to, the doctor being removed from
the DDL or ADL by action of the Division, or the doctor retiring and closing
the doctor's practice. Based on the fact that the designated doctor is a doctor
selected by the Division to provide resolution to numerous issues, the Division
expects designated doctors to comply with all requirements to be a designated
doctor, including not being removed from the DDL or removing himself or herself
voluntarily. To respond to a request for clarification regarding the doctor's
report, the doctor must be on the DDL at the time of the request for clarification.
Comment: A commenter recommends language that would require the Division
to contact the designated doctor if a party requested clarification. The recommended
language would remove any discretion on the Division's part in determining
if the clarification was appropriate.
Agency Response: The Division disagrees, as the Division's experience has
been that all requests for letters of clarification are not valid, or the
issues have previously been addressed.
Comment: A commenter requests that "clarification" be defined.
Agency Response: The Division disagrees. Clarification has a clear meaning
and common understanding, which is to provide information or response to a
question that would remove any confusion, or misunderstanding of what was
previously provided or stated.
Comment: A commenter states letters of clarification should be used sparingly
when there is true ambiguity about the interpretation/application of the Guides
to the Evaluation of Permanent Impairment. Another commenter states that a
request for clarification should not result in a reexamination. However, the
commenter contends providing new medical evidence for the designated doctor
to review and consider may be a good reason for a reexamination.
Agency Response: The Division agrees. The Division will use its discretion
when determining when a letter of clarification is needed. A letter of clarification,
in and of itself, does not automatically result in a reexamination. The designated
doctor's review of the questions or any additional medical evidence determines
the need for a reexamination.
§126.7(w)(1): Several commenters recommend amending the 10-day timeframe
to 20 or 30 days to prevent the selection of a subsequent designated doctor.
Agency Response: The Division agrees. Labor Code §408.0041(b) provides
the exam shall be conducted with 21 days of the Commissioner's order. The
language has been changed to require the rescheduled exam to be conducted
within 21 days of the Commissioner's order.
§126.7(w)(2): Several commenters recommend adding language that will
clarify that selection of an alternate designated doctor is appropriate if
the designated doctor refuses to respond to a letter of clarification.
Agency Response: The Division disagrees. The determination to select a
subsequent designated doctor needs to be reviewed by the Division on a case-by-case
basis due to unforeseen circumstances encountered by the designated doctor,
or based on the reason for the non-response. Therefore, the determination
to select a subsequent designated doctor will be addressed through internal
procedure and training of Division staff.
§126.7(w)(2): A commenter states that there should be reasonable opportunity
for repeat examinations to prevent "gaming" of the system by repeatedly asking
for letters of clarification in hopes that the designated doctor cannot make
the deadline.
Agency Response: The Division agrees. The timeframe to reschedule a repeat
examination has been extended to within 21 days from the date of the Commissioner's
order in §126.7(w)(2).
For, with changes: Rehab for Workers; Texas Association of School Boards;
ECAS WC Services; Texas Mutual Insurance Company; Association of Fire &
Casualty Insurers of Texas; Insurance Council of Texas; TIRR Systems; Texas
Medical Association; Office of Injured Employee Counsel; Lockheed Martin Aeronautics
Company; The Boeing Company; Medical Equation, Inc.; HealthSouth Corporation;
and Various Individuals.
Against: An individual.
The amendments to §126.5 and §126.6 and new §126.7
are adopted under Labor Code §§408.004, 408.0041, 408.151, 402.00111,
and 402.061. Section 408.004 provides for required medical examinations. Section
408.0041 provides for designated doctor examinations. Section 408.151 provides
for required medical examinations and designated doctor examinations during
supplemental income benefits. Section 402.00111 provides that the Commissioner
of Workers' Compensation shall exercise all executive authority, including
rulemaking authority, under the Labor Code and other laws of this State. Section
402.061 authorizes the Commissioner to adopt rules necessary to administer
the Act.
§126.5.Entitlement and Procedure for Requesting Required Medical Examinations.
(a)
A doctor who has contracted with or is employed by an authorized
workers' compensation health care network established under Insurance Code
Chapter 1305, (network doctor) may not perform a required medical examination,
as those terms are used under the Texas Workers' Compensation Act (the Act),
for an employee receiving medical care through the same network. It is the
responsibility of the requesting party to ensure the doctor selected does
not have a disqualifying association.
(b)
The Division may authorize a required medical examination
(RME) for any reason set forth in the Act, Texas Labor Code §408.004, §408.0041,
or §408.151 at the request of the insurance carrier (carrier). The request
shall be made in the form and manner prescribed by the Division. A carrier
is not entitled to take action with respect to benefits based on, and the
Division shall not consider, a report of an RME doctor that was not approved
or obtained in accordance with this section.
(c)
Carriers are entitled to RMEs by a doctor of their choice
in accordance with this subsection as follows:
(1)
Pursuant to Texas Labor Code §408.004, once every
180 days, to resolve any questions about the appropriateness of the health
care received by the injured employee (employee). The carrier's first RME
may be requested at any time after the date of injury. A subsequent examination
may be requested once every 180 days after the first examination and must
be performed by the same doctor unless otherwise approved by the Division.
This paragraph only applies to requests for required medical examinations
of employees not receiving medical treatment through an authorized workers'
compensation health care network.
(2)
For the purpose of evaluating a designated doctor's determination
on the issues listed under Labor Code §408.0041, a carrier is entitled
to an examination under this subsection only after a Designated Doctor exam
under §126.7 of this title (relating to Designated Doctor Examinations:
Requests and General Procedures).
(3)
For the purpose of evaluating a designated doctor's determination
pursuant to Texas Labor Code §408.151, to determine if the employee's
medical condition resulting from the compensable injury has improved sufficiently
to allow the employee to return to work. For the purposes of this paragraph,
the carrier may not require an employee to submit to an RME more than once
per year if:
(A)
an employee is receiving supplemental income benefits on
or after the second anniversary of the date of the employee's initial entitlement
to supplemental income benefits, and
(B)
in the year preceding the request for the RME, the employee's
medical condition resulting from the compensable injury had not improved sufficiently
to allow the employee to return to work during that year.
(d)
The doctor selected to perform an RME must be on the Division's
approved doctors list and, if the purpose of the examination is to evaluate
maximum medical impairment (MMI) and/or permanent impairment following a designated
doctor examination, be authorized to assign impairment ratings under §130.1(a)
of this title (relating to Certification of Maximum Medical Improvement and
Evaluation of Permanent Impairment).
(e)
Except for an examination under subsection (c)(2) and (3)
of this section, the Division shall not require an employee to submit to a
medical examination at the carrier's request until the carrier has made an
attempt to obtain the agreement of the employee for the examination as required
by this subsection. The carrier shall notify the Division in the form and
manner prescribed by the Division of any agreement or non-agreement by the
employee regarding the requested examination. An examination of an employee
by a doctor selected by the carrier shall be requested as follows:
(1)
Prior to requesting an RME from the Division, the carrier
shall send a copy of the request to the employee and the employee's representative
(if any) in the manner prescribed by subsection (g) of this section in an
attempt to obtain the employee's agreement to the examination.
(2)
The carrier shall give the employee 15 days to agree to
the examination. The 15-day period begins on the date the carrier sends the
request to the employee and the employee's representative (if any). Though
the employee has 15 days to respond to the request, the carrier is not prohibited
from contacting the employee or the employee's representative (if any) by
telephone to discuss the request and obtain the employee's or the representative's
response.
(3)
The carrier shall send the request to the Division after
either obtaining the employee's answer to the request or when the employee
fails to respond after the 15-day period.
(f)
The carrier shall send a copy of the request for a required
medical examination required by subsection (e) of this section to the employee
and the employee's representative (if any) by facsimile or electronic transmission
if the carrier has been provided with a facsimile number or email address
for the recipient, otherwise, the carrier shall send the request by other
verifiable means.
(g)
The carrier shall maintain copies of the request for a
required medical examination and shall also maintain verifiable proof of successful
transmission of the information. For these purposes, verifiable proof includes,
but is not limited to, a facsimile confirmation sheet, certified mail return
receipt, delivery confirmation from the postal or delivery service, or a copy
of the electronic submission.
(h)
This section is effective on January 1, 2007 and a request
for an RME under this section may be made on or after January 1, 2007.
§126.6.Required Medical Examination.
(a)
When a request is made by the insurance carrier (carrier),
or the Division, for a medical examination, the Division shall determine if
an examination should occur. The Division shall grant or deny the request
within seven days of the date the request is received by the Division. A copy
of the action of the Division shall be sent to the injured employee (employee),
the employee's representative (if any), and the carrier. The notice shall
explain the circumstances under which an employee may experience loss of benefits
and penalty exposure for failing to attend the examination as well as the
need to reschedule a missed examination. An agreement between the parties
for an examination under §126.5 of this title (relating to Entitlement
and Procedure for Requesting Required Medical Examinations) that the carrier
has a right to has the same effect as the action of the Division.
(b)
All examinations required under this section must be scheduled
to occur within 30 days after receipt of the notice, with at least 10 days
notice to the employee and the employee's representative (if any). If a scheduling
conflict exists, the employee and the doctor shall contact each other. The
doctor or the employee who has the scheduling conflict must make contact at
least 24 hours prior to the appointment. The 24-hour requirement will be waived
in an emergency situation (such as a death in the immediate family or a medical
emergency). The rescheduled examination shall be set for a date within seven
days of the originally scheduled examination, unless an extension is agreed
upon by the employee and doctor. The extension may not be to a date later
than the 30th day after the originally scheduled examination. In this event,
the examining doctor shall notify the carrier and the 10 days notice requirement
does not apply to a rescheduled examination.
(c)
The employee's treating doctor may be present at an examination
scheduled with a doctor selected by the carrier. The employee's treating doctor
may observe the conduct of the examination, and may consult with the examining
doctor about the course of the employee's treatment. The employee's treating
doctor shall not otherwise participate in, impede, or advise the employee
not to cooperate with the examination. In initially scheduling the examination,
a reasonable attempt shall be made to accommodate the schedule of the treating
doctor if the employee wants the treating doctor to attend the examination
and the treating doctor is willing to do so. However, once an examination
is scheduled based on the treating doctor's availability, the examination
shall not be delayed, canceled, or rescheduled due to the treating doctor's
scheduling conflicts unless:
(1)
the required medical examination (RME) doctor agrees to
the rescheduling; or
(2)
the examination was canceled by the RME doctor.
(d)
If the RME doctor, selected by a carrier, refuses to allow
the treating doctor to attend the examination, the carrier shall cancel the
appointment and request that another doctor be approved for the RME. If reasonable
notice is not provided to the employee and the employee's representative (if
any), the carrier shall be liable for any reasonable travel expenses incurred
by the employee and for the payment for the treating doctor's attendance at
a refused appointment. This subsection shall not apply to situations where
the treating doctor is not able to attend the examination due to any form
of scheduling conflict.
(e)
An RME doctor, selected by the carrier or the Division,
who conducts an examination regarding the appropriateness of the health care
received by the employee, shall complete a medical report that includes objective
findings of the examination and an analysis that explains how the medical
condition and objective findings lead to the conclusion reached by the doctor.
In addition, the RME doctor shall file the report with the insurance carrier
by facsimile or electronic transmission, and shall file the report with the
employee and the employee's representative (if any) by facsimile or by electronic
transmission if the RME doctor has been provided with a facsimile number or
email address for the recipient, otherwise, the RME doctor shall send the
report by other verifiable means. Written notice is verifiable when it is
provided from any source in a manner that reasonably confirms delivery to
the party. This may include an acknowledged receipt by the injured employee
or insurance carrier, a statement of personal delivery, confirmed by e-mail,
confirmed delivery by facsimile, or some other confirmed delivery to the home
or business address. The goal of this requirement is not to regulate how a
system participant makes delivery of a report or other information to another
system participant, but to ensure that the system participant filing the report
or providing the information has verifiable proof that it was delivered.
(f)
An RME doctor who, subsequent to a designated doctor's
examination, determines the employee has reached maximum medical improvement
(MMI) or who assigns an impairment rating, shall complete and file the report
as required by §130.1 and §130.3 of this title (relating to Certification
of Maximum Medical Improvement and Evaluation of Permanent Impairment and
Certification of Maximum Medical Improvement and Evaluation of Permanent Impairment
by Doctor Other than the Treating Doctor). Otherwise, the RME doctor shall
not certify MMI or assign an impairment rating. If the RME doctor disagrees
with the designated doctor's opinion regarding MMI, the RME doctor's report
shall explain why the RME doctor believes the designated doctor was mistaken
or why the designated doctor's opinion is no longer valid. Other reports shall
be completed in the form and manner prescribed by the Division and shall be
sent to the carrier, the employee, the employee's representative, if any,
the treating doctor, and Division no later than 10 days after the examination.
(g)
An RME doctor who, subsequent to a designated doctor's
examination, determines that the employee can return to work immediately with
or without restrictions is required to file a Work Status Report, as described
in §129.5 of this title (relating to Work Status Reports) within seven
days of the date of the examination of the employee. This report shall be
filed with the treating doctor and the carrier by facsimile or electronic
transmission. In addition, the RME doctor shall file the report with the employee
and the employee's representative (if any) by facsimile or by electronic transmission
if the RME doctor has been provided with a facsimile number or email address
for the recipient, otherwise, the RME doctor shall send the report by other
verifiable means.
(h)
An RME doctor who, subsequent to a designated doctor's
examination, addresses issues other than those listed in subsections (f) and
(g) of this section, shall file a narrative report within seven days of the
date of the examination of the employee. This report shall be filed with the
treating doctor and the carrier by facsimile or electronic transmission. In
addition, the RME doctor shall file the report with the employee and the employee's
representative (if any) by facsimile or by electronic transmission if the
RME doctor has been provided with a facsimile number or email address for
the recipient, otherwise, the RME doctor shall send the report by other verifiable
means.
(i)
A doctor who conducts an examination solely under the authority
of this rule shall not be considered a designated doctor under the Labor Code §408.0041, §408.122
or §408.125. Examinations with a designated doctor are not subject to
any limitations under the provisions for RMEs.
(j)
A carrier may suspend temporary income benefits (TIBs)
if an employee, without good cause, fails to attend an RME required pursuant
to Labor Code §408.0041(f).
(1)
In the absence of a finding by the Division to the contrary,
a carrier may presume that the employee did not have good cause to fail to
attend the examination if by the day the examination was originally scheduled
to occur the employee has both:
(A)
failed to submit to the examination; and
(B)
failed to contact the RME doctor's office to reschedule
the examination in accordance with subsection (b) of this section.
(2)
If, after the carrier suspends TIBs pursuant to this section,
the employee contacts the RME doctor to reschedule the examination, the RME
doctor shall reschedule the examination as soon as possible, but not later
than the 30th day after the employee contacted the doctor. The insurance carrier
shall re-initiate TIBs effective as of the date the employee submitted to
the examination. The re-initiation of TIBs shall occur no later than the seventh
day following:
(A)
the date the carrier was notified that the employee attended
the examination; or
(B)
the date that the carrier was notified that the Division
found that the employee had good cause for not attending the examination.
(3)
An employee is not entitled to TIBs for a period during
which the carrier was entitled to suspend benefits pursuant to this section
unless the employee later submits to the examination and the Division finds
or the carrier determines that the employee had good cause to fail to attend
the appointment.
(k)
An employee who, without good cause, fails or refuses to
appear at the time scheduled for an examination authorized by this section
may be assessed an administrative penalty under Labor Code §408.004 and §408.0041.
An employee who fails to submit to an examination at the carrier's request
when the carrier selected doctor refuses to allow the treating doctor to attend
the examination or when the RME doctor cancels the examination does not commit
an administrative violation.
(l)
The Division shall require examinations requiring travel
of up to 75 miles from the employee's residence, unless the treating doctor
certifies that such travel may be harmful to the employee's recovery. Travel
over 75 miles may be authorized if good cause exists to support such travel.
The carrier shall pay reasonable travel expenses incurred by the employee
in submitting to any required medical examination, as specified in Chapter
134 of this title (relating to Benefits--Guidelines For Medical Service, Charges,
and Payments).
(m)
This section is effective on January 1, 2007 and a request
for an RME under this section may be made on or after January 1, 2007.
§126.7.Designated Doctor Examinations: Requests and General Procedures.
(a)
The Division may require a medical examination by a designated
doctor at the request of the insurance carrier, an injured employee (employee),
the employee's representative, if any, the medical advisor, or on its own
motion. A doctor who has contracted with or is employed by an authorized workers'
compensation health care network established under Chapter 1305, Insurance
Code, (network doctor) may not perform a designated doctor examination, as
those terms are used under the Texas Workers' Compensation Act, for an employee
receiving medical care through the same network.
(b)
The request shall be made in the form and manner prescribed
by the Division.
(c)
A designated doctor examination shall be used to resolve
questions about the following:
(1)
the impairment caused by the employee's compensable injury;
(2)
the attainment of maximum medical improvement (MMI);
(3)
the extent of the employee's compensable injury;
(4)
whether the employee's disability is a direct result of
the work-related injury;
(5)
the ability of the employee to return to work (RTW); or
(6)
issues similar to those described by paragraphs (1) - (5)
of this subsection.
(d)
The report of the designated doctor is given presumptive
weight regarding the issue(s) in question and/or dispute, unless the preponderance
of the evidence is to the contrary.
(e)
The Division, within 10 days after approval of a valid
request, shall issue a written notice that assigns a designated doctor; requires
an exam to be conducted on a date no earlier than 14 days, but no later than
21 days from the date of the written notice; and notify the designated doctor,
the employee, the employee's representative, if any, and the insurance carrier
that the designated doctor will be directed to examine the employee. The written
notice shall:
(1)
indicate the designated doctor's name, license number,
practice address and telephone number, and the date and time of the examination
or the date range for the examination to be conducted;
(2)
explain the purpose of the designated doctor examination;
(3)
require the employee to submit to an examination by the
designated doctor; and
(4)
require the treating doctor and insurance carrier to forward
all medical records in compliance with subsection (i)(3) of this section.
(f)
The designated doctor's office and the employee shall contact
each other if there exists a scheduling conflict for the designated doctor
appointment. The designated doctor or the employee who has the scheduling
conflict must make the contact at least 24 hours prior to the appointment.
The 24-hour requirement will be waived in an emergency situation (such as
a death in the immediate family or a medical emergency). The rescheduled examination
shall be set to occur within 21 days of the originally scheduled examination.
Within 24 hours of rescheduling, the designated doctor shall contact the Division's
field office and the insurance carrier with the time and date of the rescheduled
examination. If the examination cannot be rescheduled within 21 days, the
designated doctor shall notify the Division and the Division shall select
a new designated doctor.
(g)
An insurance carrier may suspend temporary income benefits
(TIBs) if an employee, without good cause, fails to attend a designated doctor
examination.
(1)
In the absence of a finding by the Division to the contrary,
an insurance carrier may presume that the employee did not have good cause
to fail to attend the examination if by the day the examination was originally
scheduled to occur the employee has both:
(A)
failed to submit to the examination; and
(B)
failed to contact the designated doctor's office to reschedule
the examination in accordance with subsection (f) of this section.
(2)
If, after the insurance carrier suspends TIBs pursuant
to this subsection, the employee contacts the designated doctor to reschedule
the examination, the designated doctor shall schedule the examination to occur
as soon as possible, but not later than the 21st day after the employee contacted
the doctor. The insurance carrier shall reinstate TIBs effective as of the
date the employee submitted to the examination unless the report of the designated
doctor indicates that the employee has reached MMI or is otherwise not eligible
for income benefits. The re-initiation of TIBs shall occur no later than the
seventh day following:
(A)
the date the insurance carrier was notified that the employee
submitted to the examination; or
(B)
the date that the carrier was notified that the Division
found that the employee had good cause for not attending the examination.
(3)
An employee is not entitled to TIBs for a period during
which the insurance carrier suspended benefits pursuant to this subsection
unless the employee later submits to the examination and the Division finds
or the insurance carrier determines that the employee had good cause for failure
to attend the examination.
(h)
If at the time the request is made, the Division has previously
assigned a designated doctor to the claim, the Division shall use that doctor
again, if the doctor is still qualified and available. Otherwise, the Division
shall select the next available doctor on the Division's Designated Doctor
List (DDL) who:
(1)
has not previously treated or examined the employee within
the past 12 months and has not examined or treated the employee with regard
to a medical condition being evaluated in the designated doctor examination;
(2)
does not have any disqualifying associations as described
in §180.21 of this title (relating to Division Designated Doctor List);
and
(3)
has credentials appropriate to the issue in question and
the employee's medical condition.
(i)
The designated doctor is authorized to receive the employee's
confidential medical records to assist in the resolution of a dispute under
this section without a signed release from the employee.
(1)
The treating doctor and insurance carrier shall provide
to the designated doctor copies of all the employee's medical records in their
possession relating to the medical condition to be evaluated by the designated
doctor. For subsequent examinations with the same designated doctor, only
those medical records not previously sent must be provided.
(2)
The treating doctor and insurance carrier may also send
the designated doctor an analysis of the employee's medical condition, functional
abilities, and return-to-work opportunities. The analysis may include supporting
information such as videotaped activities of the employee, as well as marked
copies of medical records. If the insurance carrier sends an analysis to the
designated doctor, the insurance carrier shall send a copy to the treating
doctor, the employee, and the employee's representative, if any. If the treating
doctor sends an analysis to the designated doctor, the treating doctor shall
send a copy to the insurance carrier, the employee, and the employee's representative,
if any.
(3)
The treating doctor and insurance carrier shall ensure
that the required records and analyses (if any) are mailed to the designated
doctor no later than the fifth working day prior to the date of the designated
doctor examination.
(4)
If the designated doctor has not received the medical records
or any part thereof at least one working day prior to the examination, the
designated doctor shall:
(A)
report this violation to the Division's Compliance and
Practices section; and
(B)
reschedule the examination in accordance with subsection
(f) of this section. The doctor shall conduct the rescheduled examination
regardless of whether or not the complete medical record has been timely received.
(j)
The designated doctor shall review the employee's medical
records, including an analysis of the employee's medical condition, functional
abilities and return to work opportunities provided by the insurance carrier
and treating doctor, as well as the employee's medical condition and history
as provided by the injured employee, and shall perform a complete physical
examination. The designated doctor shall give the medical records reviewed
the weight the doctor determines to be appropriate.
(k)
The designated doctor shall perform additional testing
or refer an employee to other health care providers when necessary to determine
the issue in question. Any additional testing required for the evaluation
is not subject to preauthorization requirements in accordance with the Labor
Code §413.014 or Insurance Code, Chapter 1305. Any additional testing
must be completed within 10 working days of the designated doctor's physical
examination of the employee. The need for additional testing under this subsection
extends the amount of time the designated doctor has to file the report by
10 working days.
(l)
To avoid undue influence on the designated doctor:
(1)
except as provided by subsection (i) of this section, only
the employee or appropriate Division staff may communicate with the designated
doctor prior to the examination of the employee by the designated doctor regarding
the employee's medical condition or history;
(2)
after the examination is completed, communication with
the designated doctor regarding the employee's medical condition or history
may be made only through appropriate Division staff; and
(3)
the designated doctor may initiate communication with any
doctor who has previously treated or examined the employee for the work-related
injury or with a peer review doctor identified by the insurance carrier who
examined the employee's claim.
(m)
The insurance carrier, treating doctor, employee, or employee's
representative, if any, may contact the designated doctor's office to ask
about administrative matters such as whether the designated doctor received
the records, whether the exam took place, or whether the report has been filed,
or similar matters.
(n)
A designated doctor who determines the employee has reached
maximum medical improvement (MMI) or who assigns an impairment rating, or
who determines the employee has not reached MMI, shall complete and file the
report as required by §130.1 and §130.3 of this title (relating
to Certification of Maximum Medical Improvement and Evaluation of Permanent
Impairment and Certification of Maximum Medical Improvement and Evaluation
of Permanent Impairment by Doctor Other than the Treating Doctor). The report
shall be completed in the form and manner prescribed by the Division and shall
be sent to the carrier, the employee, the employee's representative, if any,
the treating doctor, and Division.
(o)
A designated doctor who determines that the employee can
return to work immediately with or without restrictions is required to file
a Work Status Report, as described in §129.5 of this title (relating
to Work Status Reports) within seven days of the date of the examination of
the employee. This report shall be filed with the treating doctor and the
carrier by facsimile or electronic transmission. In addition, the designated
doctor shall file the report with the employee and the employee's representative
(if any) by facsimile or by electronic transmission if the designated doctor
has been provided with a facsimile number or email address for the recipient,
otherwise, the designated doctor shall send the report by other verifiable
means.
(p)
A designated doctor who addresses issues other than those
listed in subsections (n) and (o) of this section, shall file a narrative
report within seven days of the date of the examination of the employee. This
report shall be filed with the treating doctor and the carrier by facsimile
or electronic transmission. In addition, the designated doctor shall file
the report with the employee and the employee's representative (if any) by
facsimile or by electronic transmission if the designated doctor has been
provided with a facsimile number or email address for the recipient, otherwise,
the designated doctor shall send the report by other verifiable means.
(q)
The designated doctor shall maintain accurate records,
including the employee records, analysis (including supporting information),
and narratives provided by the insurance carrier and treating doctor, to reflect:
(1)
the date and time of any designated doctor appointments
scheduled with an employee;
(2)
the circumstances regarding a cancellation, no-show or
other situation where the examination did not occur as initially scheduled
or rescheduled;
(3)
the date of the examination;
(4)
the date medical records were received from the treating
doctor or any other person or organization;
(5)
the date the medical evaluation report, including the narrative
report described in subsection (n) of this section, was submitted to all parties;
(6)
the name of all referral health care providers, date of
appointments and reason for referral by the designated doctor; and
(7)
the date the doctor contacted the Division for assistance
in obtaining medical records from the insurance carrier or treating doctor.
(r)
The insurance carrier shall pay any accrued income benefits,
and shall begin or continue to pay weekly income benefits, in accordance with
the designated doctor's report for the issue(s) in dispute, no later than
five days after receipt of the report or five days after receipt of notice
from the Division, whichever is earlier.
(s)
The insurance carrier, the employee, and the employee's
representative (if any) is not entitled to a subsequent designated doctor
examination until the earlier of:
(1)
the 60th day after the prior designated doctor examination
was held; or
(2)
the date the insurance carrier or the employee is found
by the Division to have good cause, such as the inclusion of additional body
parts (extent of injury).
(t)
On or after the second anniversary of the initial award
of Supplemental Income Benefits (SIBs), the insurance carrier may not require
an employee who is receiving SIBs to submit to a designated doctor examination
more than annually, if in the preceding year, the employee's medical condition
resulting from the compensable injury has not improved sufficiently to allow
the employee to return to work.
(u)
Parties may file a request with the Division for clarification
of the designated doctor's report. A copy of the request must be provided
to the opposing party. The Division may contact the designated doctor if it
determines that clarification is necessary to resolve an issue regarding the
designated doctor's report. The Division, at its discretion, may request clarification
from the designated doctor on issues the Division deems appropriate. To respond
to the request for clarification, the designated doctor must be on the Division's
DDL at the time the request is received by the Division. The designated doctor
shall respond to the letter of clarification within five days of receipt.
If, in order to respond to the request for clarification, the designated doctor
has to reexamine the injured employee, the doctor shall:
(1)
respond to the request for clarification advising of the
need for an additional examination within five days of receipt and provide
copies of the response to the parties specified in subsection (p) of this
section; and
(2)
conduct the reexamination within 21 days from the request
by the Division at the location of the original examination.
(v)
Upon receipt of a request for a benefit review conference,
the Division shall resolve a dispute of the opinion of a designated doctor
through the dispute resolution processes outlined in Chapters 140 - 147 of
this title (relating to Dispute Resolution).
(w)
This section is effective on January 1, 2007 and a request
for a designated doctor under this section may be made on or after January
1, 2007.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on July 27, 2006.
TRD-200603953
Norma Garcia
General Counsel
Texas Department of Insurance, Division of Workers' Compensation
Effective date: January 1, 2007
Proposal publication date: February 3, 2006
For further information, please call: (512) 804-4288
28 TAC §126.7
The Commissioner of the Division of Workers’ Compensation,
Texas Department of Insurance, adopts the repeal of §126.7, concerning
suspension of temporary income benefits based on the opinion of a carrier-selected
required medical examination doctor. The repeal is adopted without changes
to the proposal published in the February 3, 2006, issue of the
Texas Register
(31 TexReg 670).
The repealed section is necessary to implement changes to the Labor Code §408.004
as a result of House Bill (HB) 7, enacted by the 79th Legislature, Regular
Session, effective September 1, 2005. HB 7 changed the Labor Code §408.004
by limiting the reasons an injured employee (employee) may be required to
attend a required medical examination prior to a designated doctor examination
to the issue of appropriateness of the health care received by the employee.
HB 7 also removed the provision for the suspension of temporary income benefits
for failure to attend the required medical examination on that issue. HB 7
changed Labor Code §408.0041 to provide the designated doctor's opinion
presumptive weight regarding entitlement and payment of income benefits and
to address the suspension of temporary income benefits only for failure to
attend a required medical exam after a designated doctor exam. These statutory
changes provide procedural guidance to suspend benefits based on the opinion
of the designated doctor or the actions (failure to attend) of the employee,
rather than on a report or opinion of a required medical examination doctor.
Section 126.7 is repealed effective December 31, 2006, as it is no longer
applicable since there are no situations in which temporary income benefits
may be suspended based on the opinion of the required medical examination
doctor. The Division simultaneously adopts new §126.7, which is effective
January 1, 2007, regarding designated doctor exams, which is published elsewhere
in this issue of the
Texas Register
. New §126.7
provides procedural guidance regarding the request for, and selection of,
a designated doctor. The new section also provides procedural guidance regarding
the responsibilities of the designated doctor.
Comment: A commenter objects to required medical exams (RMEs) performed
by carrier-paid physicians as biased and believes the RMEs should only be
performed by designated doctors.
Agency Response: The Division disagrees. Labor Code §§408.004,
408.0041, and 408.151 specifically provide for medical exams to be conducted
by a doctor selected by the carrier.
For: None.
Against: An individual.
The repeal is adopted under the Labor Code §§408.0041,
402.00111, and 402.061. Section 408.0041 provides for designated doctor examinations.
Section 402.00111 provides that the Commissioner of Workers' Compensation
shall exercise all executive authority, including rulemaking authority, under
the Labor Code and other laws of this state. Section 402.061 provides the
Commissioner the authority to adopt rules as necessary to implement and enforce
the Texas Workers' Compensation Act.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on July 27, 2006.
TRD-200603952
Norma Garcia
General Counsel
Texas Department of Insurance, Division of Workers' Compensation
Effective date: December 31, 2006
Proposal publication date: February 3, 2006
For further information, please call: (512) 804-4288
Subchapter A. IMPAIRMENT INCOME BENEFITS
28 TAC §130.2, §130.6
The Commissioner of the Division of Workers' Compensation,
Texas Department of Insurance, adopts amendments to §130.2 and §130.6,
concerning certification of maximum medical improvement (MMI), impairment
rating (IR), and designated doctor examinations for MMI and IR. The amended
sections are adopted with changes to the proposed text as published in the
February 3, 2006, issue of the
Texas Register
(31
TexReg 675).
The adopted amendments are necessary to implement changes to Labor Code §408.123
and §408.0041, as a result of House Bill (HB) 7 enacted by the 79th Legislature,
Regular Session. HB 7 amended Labor Code §408.123 to require the treating
doctor provide information to the injured employee (employee) for disputing
a certification of MMI and the assignment of an IR. The adopted amendments
to §130.2 set forth the process for the treating doctor to provide the
notification to the employee. Since these certifications may occur for both
network and non-network health care services, the additional notification
ensures that the employee is notified of the assignment of the MMI/IR as soon
as reasonably possible. This notice will be provided to the employee, along
with the Report of Medical Evaluation, through the processes outlined in §130.1.
The adopted amendments to §130.6 address changes made to Labor Code §408.0041.
The amendments delete the procedures set forth in existing subsections (a)
- (h) and (k) since these have been moved, with modifications as appropriate,
to adopted §126.7, which is published elsewhere in this issue of the
The adopted amendments to §130.2 address changes made to Labor Code §408.123.
This section requires the treating doctor to examine the injured employee
to determine if the employee has any permanent impairment as a result of the
compensable injury. If the treating doctor is not authorized by the Division
to certify MMI and assign an impairment rating, the doctor must refer the
employee to another doctor that is authorized by the Division for the certification.
At the conclusion of the examination the doctor shall provide the employee
written notice that the certification may be disputed. As a result of public
comment, changes were made to §130.2 to provide that at the end of the
examination a separate written notice that certification may be disputed will
be provided with the Report of Medical Evaluation, as required by §130.1,
in English or Spanish or other language common to the employee. The notice
will also contain information that the impairment rating becomes final within
90 days if not disputed by the employee or the employee's representative.
The Division shall mail a notice to the treating doctor, employee, the employee's
representative, if any, and the insurance carrier on the expiration of 98
weeks from the date the employee's Temporary Income Benefits (TIBs) began
to accrue. The Division has also removed the requirement for rescheduled examinations
due to a prospective date of MMI based on public comments.
The adopted amendments to §130.6 address changes made to Labor Code §408.0041.
Section 130.6 provides procedural direction and guidance regarding the roles
and responsibilities of the designated doctor when performing an examination
for MMI/IR. Subsection (a) states any evaluation for maximum medical improvement
(MMI) and/or impairment rating (IR) shall be conducted in accordance with §130.1.
Subsection (b) provides direction regarding the expectation of the designated
doctor based on the absence or existence of MMI/IR certifications, and prohibits
a designated doctor, who determines the employee has not reached maximum medical
improvement (MMI) from assigning an impairment rating.
Subsection (f) provides that when the designated doctor issues multiple
impairment ratings due to an unresolved dispute over the extent of the employee's
compensable injury, the carrier shall pay benefits based on the conditions
that have not been disputed by the carrier or have been finally adjudicated
by the Division to be part of the compensable injury. A date on which a designated
doctor may be requested has been added to the section as a result of comments.
§130.2
General: A commenter believes the estimated savings in the first 30 - 60
days would be $90 million for functional capacity exams, including MRIs and
EMGs. Another commenter complains that the rules only have minor changes and
are flawed. The commenter believes that HB 7 was needed but the proposed rules
do not correct the flaws in the system.
Agency Response: The amendments to §130.2 address the new requirement
of HB 7 for the treating doctor to provide the injured employee a notice of
MMI/IR, and that the rating may become final if not disputed within 90 days
of receipt. The Division is unaware of the source of the estimated cost savings
and the questions posed by the commenter are not germane to the proposed rule.
The Division agrees that HB 7 was needed and believes that the rules comply
with the requirements of HB 7. The Division believes that the rules improve
the existing process and provide the necessary process for employees to receive
notice of MMI/IR.
Comment: A commenter feels Labor Code §408.123 does not place the
burden to notify the employee on the treating doctor.
Agency Response: The Division disagrees. Labor Code §408.123 clearly
places the responsibility to provide the notice to the employee on the treating
doctor.
Comment: Some commenters recommend that the Division include the notice
required by Labor Code §408.123 in the instructions of the DWC Form-69
as the instructions are on the back side of the form rather than requiring
a new form as this will provide a more streamlined process.
Agency Response: The Division disagrees. The instructions provide guidance
in completing the form. Even if provided in the instructions, the Division
does not expect many injured employees would read the instructions since they
will not be completing the form. Additionally, the instructions are on the
back of the DWC-69 only if copied onto the back of the form. It is the Division's
experience that most DWC-69s received by the Division include only the front
page of the form, not the instructions. The intent of Labor Code §408.123
is to provide the injured employee a separate and distinct notice that MMI/IR
had been assigned and that the employee can dispute it. Including the language
on the DWC-69 would not meet this intent.
§130.2(a)(3): A commenter states the rule appears to meet the intent
of Labor Code §408.123 and requests that the notice be required in English
and Spanish. The commenter also requests the Division create a standard form
and make it available to all doctors. Several commenters request that the
notice include language that the impairment rating may become final if not
disputed in 90 days.
Agency Response: The Division agrees. The language has been changed to
require the notice to be in English, or Spanish, or other common language
to the employee. The Division does not believe that a separate form is necessary
but will prepare and post on the Division's webpage a sample notice that contains
language that can be downloaded and used by the doctor's office that meets
the rules requirements. The language will include language regarding the 90-day
timeframe for disputing the assigned IR.
Comment: Several commenters feel the requirement to provide the notice
at the conclusion of the exam is unreasonable and recommend that the notice
be provided no later than five days after the conclusion of the exam. The
commenters assert that this will allow the doctor time to complete necessary
calculations and prevent the injured employee from having to wait at the doctor's
office. Another commenter recommends deleting this paragraph as redundant
and requests clarification of "conclusion of the exam."
Agency Response: The Division agrees and has changed the requirement. The
notice must be provided with the Report of Medical Examination, which is filed
no later than seven days after the conclusion of the exam in accordance with §130.1.
The Division disagrees that the paragraph is redundant. Labor Code §408.123
requires the Commissioner to adopt a rule to require provision of the notice
by the treating doctor. The Division disagrees that "conclusion of the exam"
needs to be clarified because the Report of Medical Evaluation is provided
in accordance with §130.1(d)(2) which provides the necessary direction
for filing the report.
Comment: Several commenters recommend that "the employee's representative,
if any" be added to the list of recipients of the 98 week notice. Other commenters
recommend sending the letter to the insurance carrier. Another commenter suggests
that the treating doctor provide a copy of the notice to the insurance carrier
and the injured employee's attorney, if any. A commenter also requests clarification
that both the DWC-69 and the notice are required to be sent.
Agency Response: The Division agrees and has added language to notify the
injured employee's representative, if any, as well as the insurance carrier.
The Division clarifies that the notice is required or addition to the DWC-69.
Comment: Several commenters don't feel the proposed language meets the
requirements of Labor Code §408.123(c) because it does not provide information
regarding how to dispute the impairment rating. The commenter provided recommended
language.
Agency Response: The notice is required to advise the injured employee
that the employee may dispute the MMI/IR. The language the Division will post
on its webpage will also advise the injured employee, or the employee's representative,
to contact the Division to dispute the MMI/IR by requesting a benefit review
conference. An unrepresented injured employee may contact the Division in
any manner to dispute the assigned MMI date and impairment rating and request
a benefit review conference. If the injured employee is represented by counsel,
the representative must file the dispute and request dispute resolution in
accordance with Labor Code Chapter 410.
§130.6: Several commenters feel requiring the designated doctor to
reschedule the exam if MMI is anticipated within 60 days will get the subsequent
exam scheduled quicker resulting in less administrative cost to the carrier;
however, they also feel that this may be used by the designated doctor to
prolong the MMI date to ensure a second exam. A commenter states that the
designated doctor could possibly no longer be qualified to examine the employee.
A commenter contends that this requirement may not work effectively for traveling
designated doctors.
Agency Response: The Division disagrees that designated doctors will abuse
this provision. However, the Division has removed the requirement for rescheduled
examinations based on a prospective date of MMI. Prospective dates are not
statutorily required and are not applicable for claims administration purposes.
The Division reminds traveling designated doctors that they should be prepared
to meet the requirements of the statute and rule if they are going to be traveling
designated doctors.
§130.6(b): Several commenters question why different requirements
exist regarding explanations of why the injured employee has reached, or not
reached, MMI/IR.
Agency Response: Different circumstances require different actions on the
part of the designated doctor. Subsection (b)(2) addresses the designated
doctor's responsibilities when only the date of MMI is in question, subsection
(b)(3) addresses the designated doctor's responsibilities when only the impairment
rating is in question, and subsection (b)(4) addresses the designated doctor's
responsibilities when both MMI and impairment rating are in question and the
designated doctor determines the injured employee has not reached MMI.
Comment: A commenter questions whether the doctor will be paid for multiple
exams when issuing multiple impairment ratings due to no agreement (dispute)
regarding the extent of injury.
Agency Response: The designated doctor will not be paid for multiple exams
for issuing multiple impairment ratings. The designated doctor will be able
to bill for each additional report of medical evaluation.
§130.6(b)(4): Several commenters request that the requirement to assign
a prospective date of MMI if the designated doctor determines the injured
employee has not reached MMI be deleted.
Agency Response: The Division agrees and has removed the requirement to
assign a prospective date of MMI and to reschedule the examination based on
a prospective date.
§130.6(e): Several commenters recommend clarifying that additional
testing not subject to preauthorization is still subject to retrospective
review. They contend that this allows carriers the means to ensure redundant
or excessive testing is not being performed and are concerned that system
medical costs will increase if the provision is not clarified.
Agency Response: The Division disagrees. A designated doctor should be
able to obtain testing as required to make an assessment of the injured employee's
condition without fear of not being reimbursed. If a party has evidence that
a designated doctor is abusing this provision, this evidence should be submitted
to the Division for appropriate enforcement action.
§130.6(f): Several commenters recommend changing the language to reflect
"accepted" rather than "not disputed" and contend that it would provide a
clearer and more affirmative response regarding the requirement to pay benefits.
Agency Response: The Division disagrees. There is an existing mechanism
for reporting to the injured employee and the Division any disputed body parts
and conditions. There is no mechanism for reporting what body parts and conditions
have been accepted.
For, with changes: Rehab for Workers; ECAS; TIRR Systems; Lockheed Martin
Aeronautics Company; Office of Injured Employee Counsel; American Insurance
Association; Texas Mutual Insurance Company; Texas Association of School Boards;
The Boeing Company; Insurance Council of Texas; Property Casualty Insurers
of America; Association of Fire and Casualty Insurers of Texas; Senator Gonzalo
Barrientos; and various individuals.
Against: An individual.
The amendments to §130.2 and §130.6 are adopted under
the Labor Code §§408.0041, 408.123, 402.061, and 402.00111. Section
408.0041 provides for designated doctor examinations. Section 408.123 provides
for certification of maximum medical improvement and evaluation of impairment
ratings. Section 402.061 requires the Commissioner of Workers' Compensation
to adopt rules necessary for the implementation and enforcement of the Texas
Workers Compensation Act. Section 402.00111 provides that the Commissioner
of Workers' Compensation shall exercise all executive authority, including
rulemaking authority, under Labor Code Title 5.
§130.2.Certification of Maximum Medical Improvement and Evaluation of Permanent Impairment by the Treating Doctor.
(a)
A treating doctor shall either examine the injured employee
(employee) and determine if the employee has any permanent impairment as a
result of the compensable injury as soon as the doctor anticipates that the
employee will have no further material recovery from or lasting improvement
to the work-related injury or illness, based on reasonable medical probability,
or have another authorized doctor do so.
(1)
A treating doctor who finds that the employee has permanent
impairment but who is not authorized to assign impairment ratings as provided
in §130.1 of this title (relating to Certification of Maximum Medical
Improvement and Evaluation of Permanent Impairment), shall make a referral
to a doctor who is authorized to do so on behalf of the treating doctor. Even
if the treating doctor is so authorized, the doctor may choose to have another
authorized doctor evaluate the employee for maximum medical improvement (MMI)
and impairment in the place of the treating doctor. However, this evaluation
shall be considered to be the report of the treating doctor.
(2)
Other than subsections (c) and (d) of this section, nothing
in this section requires a treating doctor to schedule an examination if the
employee has been released from treatment and is not receiving temporary income
benefits (TIBs). For example, when the patient is treated and released without
further treatment for a minor injury, the treating doctor is not required
to schedule and conduct an examination for MMI and permanent impairment.
(3)
At the conclusion of an examination in which the treating
doctor, or the certifying doctor in the event that the treating doctor is
not authorized to certify MMI and assign an impairment rating, determines
that the employee has reached maximum medical improvement and assigns an impairment
rating, the doctor shall provide the employee with a written notice that the
certification may be disputed. The notice shall be provided as a separate
document included with the Report of Medical Evaluation provided in accordance
with §130.1 of this title. The notice must be provided in English, Spanish,
or other language common to the employee, and shall include the following
information:
(A)
the date of maximum medical improvement;
(B)
the assigned impairment rating;
(C)
a statement that the impairment rating may become final
if not disputed within 90 days, and if the employee, or the employee's representative,
disagrees with the certification, they may dispute the certification by contacting
the Division of Workers' Compensation and requesting a benefit review conference;
(D)
the address and phone number of the local field office
of the Division of Workers' Compensation (Division); and
(E)
a statement that the employee may contact the Division
for more information at 1-800-252-7031.
(b)
A certification of MMI and assignment of an impairment
rating shall be performed and reported in accordance with the requirements
of §130.1 of this title.
(c)
The Division shall mail a notice to a treating doctor,
the employee, the employee's representative, if any, and the insurance carrier
on the expiration of 98 weeks from the date the employee's TIBs began to accrue
if the employee is still receiving TIBSs. The Division's notice shall advise
the treating doctor of the requirements under Chapter 408, Subchapter G of
the Texas Workers' Compensation Act, and this section, and require that an
impairment rating report be mailed to the Division no later than 104 weeks
from the date TIBs began to accrue.
(d)
Upon receipt of the Division's notice required in subsection
(c) of this section, the treating doctor shall schedule and conduct an examination
of the employee in accordance with §130.1 of this title to certify a
MMI date (if earlier than the statutory MMI date as defined in §130.4
of this title (relating to Presumption that Maximum Medical Improvement (MMI)
has been Reached and Resolution when MMI has not been Certified) and to assign
an impairment rating. A treating doctor who is not authorized to certify MMI
and assign impairment ratings, shall make a referral to a doctor who is authorized
to do so on behalf of the treating doctor.
(e)
If the carrier has not received a report of medical evaluation
by the date of statutory MMI:
(1)
the carrier may suspend TIBs and is not required to initiate
impairment income benefits (IIBs) until such time as it receives a report
of an impairment rating assigned in accordance with §130.1 of this title;
(2)
the carrier or the employee may request the appointment
of a designated doctor under §126.7 of this title (relating to Designated
Doctor Examinations: Requests and General Procedures); and/or
(3)
a carrier may make a reasonable assessment of what it believes
the true impairment rating should be and, if it does so, shall initiate IIBs
within five days of making the assessment. The carrier shall continue to pay
IIBs until the assessment is paid in full or is superceded by an impairment
rating assigned in accordance with §130.1 of this title.
§130.6.Designated Doctor Examinations for Maximum Medical Improvement and/or Impairment Ratings.
(a)
Any evaluation relating to either maximum medical improvement
(MMI), an impairment rating, or both, shall be conducted in accordance with §130.1
of this title (relating to Certification of Maximum Medical Improvement and
Evaluation of Permanent Impairment).
(b)
The designated doctor shall address the issue(s) in question
and any issues the Division may request the designated doctor to consider
and confine the report to only those issues.
(1)
When there has been no prior certification of MMI, the
designated doctor shall evaluate the injured employee (employee) for MMI,
and if the doctor finds that the employee reached MMI, assign an impairment
rating. If the designated doctor finds that the employee has not reached MMI,
the doctor shall identify the reason(s) that the designated doctor does not
believe the employee to have reached MMI.
(2)
When there has been a prior certification of MMI and impairment
rating and only the MMI date is in question, the designated doctor shall evaluate
the date the employee reached MMI and shall not assign an impairment rating.
If the certification of MMI in question was the treating doctor's certification
and the designated doctor finds that the employee either was not at MMI or
reached MMI on a date later than the treating doctor's certification, the
designated doctor shall provide an explanation with clinical documentation
to support why the employee had not reached MMI as of the date certified by
the treating doctor.
(3)
When the impairment rating is the only issue in question,
the doctor shall assign an impairment rating based on the employee's medical
condition on the MMI date.
(4)
When MMI and permanent whole body impairment are in question
and the designated doctor determines that the employee has not reached MMI,
the designated doctor shall not assign an impairment rating.
(5)
When the extent of the injury may not be agreed upon by
the parties (based upon documentation provided by the treating doctor and/or
insurance carrier or the comments of the employee regarding his/her injury),
the designated doctor shall provide multiple certifications of MMI and impairment
ratings that take into account the various interpretations of the extent of
the injury so that when the Division resolves the dispute, there is already
an applicable certification of MMI and impairment rating from which to pay
benefits as required by the Act.
(c)
When performing range of motion testing, if the AMA Guides
specify that additional testing be performed because of consistency requirements,
the designated doctor shall reschedule testing within seven days of the first
date of testing unless there is no clinical basis for retesting, and then,
the designated doctor shall document this in the narrative notes with the
clinical explanation for not recommending re-examination.
(d)
Range of motion, sensory, and strength testing should be
performed by the designated doctor, when applicable. If this testing is not
performed by the designated doctor, the health care provider performing the
testing must have successfully completed Division approved training, must
not have previously treated or examined the employee within the past 12 months,
and must not have examined or treated the employee with regard to the medical
condition being evaluated by the designated doctor. Use of another health
care provider to perform testing under this subsection shall not extend the
amount of time the designated doctor has to file the report and the designated
doctor is responsible for ensuring that the requirements of this chapter are
complied with.
(e)
For testing other than that listed in subsection (d) of
this section, the designated doctor may perform additional testing or refer
the employee to other health care providers when deemed necessary to assess
an impairment rating. Any additional testing required for the evaluation and
rating, is not subject to preauthorization requirements in accordance with
Labor Code §413.014 (relating to Preauthorization) and additional testing
must be completed within seven working days of the designated doctor's physical
examination of the employee. Use of another health care provider to perform
testing under this subsection can extend the amount of time the designated
doctor has to file the report by seven working days.
(f)
If the designated doctor provided multiple certifications
of MMI/impairment ratings by operation of subsection (b)(5) of this section,
the insurance carrier shall pay benefits based on the conditions that have
not been disputed, or have been finally adjudicated by the Division, to be
part of the compensable injury.
(g)
This section is effective January 1, 2007 and a request
for a designated doctor under this section may be made on or after January
1, 2007.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on July 27, 2006.
TRD-200603956
Norma Garcia
General Counsel
Texas Department of Insurance, Division of Workers' Compensation
Effective date: January 1, 2007
Proposal publication date: February 3, 2006
For further information, please call: (512) 804-4288
The Commissioner of the Division of Workers' Compensation, Texas Department
of Insurance, adopts the repeal of §130.5 and §130.110, concerning
impairment and supplemental income benefits. The repeal is adopted without
changes to the proposal as published in the February 3, 2006, issue of the
The repealed sections are necessary to implement new statutory provisions
contained in House Bill (HB) 7, enacted by the 79th Legislature, Regular Session,
effective September 1, 2005. HB 7 changed the Labor Code §408.0041 by
expanding the list of issues that a designated doctor may be asked to address
to include the injured employee's (employee) ability to return to work, the
extent of the injury, whether the employee's disability is a direct result
of the injury and similar issues. As a result of the change, the designated
doctor will now be asked to address issues that may affect the delivery of
income benefits in general, rather than just impairment income benefits (IIBs)
as is currently the case.
Section 130.5 and §130.110 are repealed effective December 31, 2006.
In response to the HB 7 changes, §130.5 is repealed as the process for
entitlement to, and request for, a designated doctor, applies to benefits
in general, and the process for entitlement to and request for a designated
doctor have been moved to new §126.7. Additionally, §130.110 is
repealed due to the changes in Labor Code §408.0041 for designated doctor
examinations and the ability of the employee to return to work. The process
for, entitlement to, and requesting a designated doctor exam regarding the
employee's ability to return to work after the second anniversary of entitlement
to supplemental income benefits (SIBs) is also addressed in new §126.7.
The combination of repealed §130.5 and §130.110 into new §126.7
will provide consistency throughout the designated doctor process regardless
of the issue being addressed. The Division simultaneously adopts new §126.7,
effective January 1, 2007, published elsewhere in this issue of the
General: Several commenters support the repeal of the rules.
Agency Response: The Division appreciates the support.
For: Insurance Council of Texas, Association of Fire & Casualty Insurers
of Texas.
Against: None.
Subchapter A. IMPAIRMENT INCOME BENEFITS
28 TAC §130.5
The repeal is adopted under the Labor Code §§408.0041,
402.00111, and 402.061. Section 408.0041 provides for designated doctor examinations.
Section 402.00111 provides that the Commissioner of Workers' Compensation
shall exercise all executive authority, including rulemaking authority, under
the Labor Code and other laws of this state. Section 402.061 provides the
Commissioner the authority to adopt rules as necessary to implement and enforce
the Texas Workers' Compensation Act.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on July 27, 2006.
TRD-200603954
Norma Garcia
General Counsel
Texas Department of Insurance, Division of Workers' Compensation
Effective date: December 31, 2006
Proposal publication date: February 3, 2006
For further information, please call: (512) 804-4288
28 TAC §130.110
The repeal is adopted under the Labor Code §§408.0041,
402.00111, and 402.061. Section 408.0041 provides for designated doctor examinations.
Section 402.00111 provides that the Commissioner of Workers' Compensation
shall exercise all executive authority, including rulemaking authority, under
the Labor Code and other laws of this state. Section 402.061 provides the
Commissioner the authority to adopt rules as necessary to implement and enforce
the Texas Workers' Compensation Act.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on July 27, 2006.
TRD-200603955
Norma Garcia
General Counsel
Texas Department of Insurance, Division of Workers' Compensation
Effective date: December 31, 2006
Proposal publication date: February 3, 2006
For further information, please call: (512) 804-4288
Subchapter B. MEDICAL BENEFIT REGULATION
Chapter 130.
IMPAIRMENT AND SUPPLEMENTAL INCOME BENEFITS
Chapter 130.
IMPAIRMENT AND SUPPLEMENTAL INCOME BENEFITS
Subchapter B. SUPPLEMENTAL INCOME BENEFITS
Chapter 180.
MONITORING AND ENFORCEMENT